for lack of wanting

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For lack of wanting: Discourses ofdesire in Ukrainian opiate substitutiontherapy programs

Jennifer J. CarrollUniversity of Washington

Abstract

Available treatments for addiction and substance abuse in Ukraine have been shaped by

the economic, political, and social shifts that have followed the country’s independence.

The introduction of methadone-based opiate substitution therapy (OST) for opiate

addicts is especially representative of this. Biomedical paradigms of addiction, its

etiology, and its treatment, promoted and paid for by international donors and elite

global health entities, are being met by Ukrainian notions of personhood and psychology

in both public discourse and clinical settings. Ukrainian physicians who work in OST

programs frequently reference desire (fej‘lhe) as the most significant factor in deter-

mining the success or failure of treatment. They refer to a desire to be treated, desire

to get better, desire to live. The moralized imperative to possess this desire to get

better is, in many ways, a reflection of how addiction and the addicted psyche is con-

structed and understood in the Ukrainian context. By exploring discourses of desire in

narratives of addiction and treatment, I examine how notions of psychology, will, and

self-control intersect, shaping the subjectivity, agency, and daily experiences of this

vulnerable population.

Keywords

desire, disease narrative, drug addiction, methadone, opiate substitution therapy,

Ukraine

Timur1 complains of terrible dreams. He sleeps badly. His body is often weak andhe suffers frequent fevers. He has tried various strategies for easing his symptoms:first methadone from the clinic, then shirka2 from the street, and now tramadol3

Corresponding author:

Jennifer J. Carroll, Department of Anthropology, University of Washington, Box 353100 Seattle, WA 98195,

USA.

Email: [email protected]

at UNIV WASHINGTON LIBRARIES on May 1, 2015tps.sagepub.comDownloaded from

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from a pharmacy that, for one reason or another, continues to sell to him. None ofthese solutions has remained effective for very long. After a while, he says, thingsalways get bad again.

Timur is enrolled in one of his region’s few methadone-based opiate substitutiontherapy (OST) programs, a treatment program for opiate addiction that provides adaily regimen of a synthetic, medical-grade opiates meant to take the place ofillegal narcotics. On paper, he is a free man. He is no longer in jail. Serious troubleswith the police are a thing of the past. He no longer wakes up worrying aboutwhere his next dose will come from or whether his body will hold out long enoughto find one. “My mornings have become peaceful,” he says. This is a positivechange. His evenings, however, are not so pleasant. This is when the headachescome, followed by the fevers, the weakness, and, finally, the dreams. “My dose [ofmethadone] right now—it’s not enough,” he complains. “It doesn’t hold me upanymore.”

When he first began receiving OST at the AIDS center in his hometown, Timurwas given 40mg of methadone per day. Soon after, he started feeling badly, and hisdoctor (a kind, middle-aged man whose patients call him by his formal name,Alexey Sergeevich) agreed to increase his dose. “We are here to help them,”Alexey once told me. “There is no reason for them to suffer when they are inour care.” As they worked to manage his symptoms, Timur’s dose crept up, bitby bit, until he reached 150mg, the upper limit of what his clinic is allowed toprescribe.

“Obviously the point is not to raise your dose, but to lower it,” Timur observed.“At these levels, I’m worried about my liver.” Unfortunately, his persistent with-drawal symptoms don’t present him a very convincing case for lowering his doseeither. Now that he’s reached the maximum methadone allowance, he has beentrying out additional cocktails of opioid analgesics—like shirka and tramadol—inthe hopes of finding a regimen that will work. His mornings are spent commutingto the AIDS center for his methadone, and his afternoons are spent seeking outother things to help him get through the night. Timur claims that he would like toquit, but the drugs have too much control over his body.

Timur is a problematic patient. He frustrates his doctor and nurses; however, theroot of their frustration does not seem to be his overt self-administration of streetdrugs in addition to the methadone. It seems clear that the staff of his OST clinicare well aware of, and reluctantly tolerate, Timur’s extracurricular activities. Theydo not chastise him. Instead, they pity him and wonder how to resolve the real issuethat lies underneath: his lack of desire to be treated.

This article addresses narratives of desire that are produced in the therapeuticenvironment of the OST clinic and reproduced by OST clinicians and patients inUkraine. It considers the ways in which appeals to the presence or absence ofdifferent forms of “desire” fit into local understandings of the social and psycho-logical mechanisms of addiction. Ethnographic data presented here is based on14 months of qualitative research conducted between 2010 and 2013 amongUkraine’s internationally funded HIV prevention and harm reduction projects,

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within which OST is a central element. I map out a model of addiction that ispopular among the medical professionals operating Ukraine’s OST programs aswell as the individual prognoses and treatment trajectories that are contingentupon that model. In my analysis, I pay close attention to the local values, histories,and structures that give shape to the physical and social body that medical practiceand therapeutic spaces attempt to render.

This analysis is germane not only to the treatment of drug addiction but also tothe greater public health project of reversing the spread of HIV and other com-municable diseases in three distinct ways. First, the therapeutic logic of OST isgrounded in the idea that addiction is a disease situated in the physical or psycho-logical state of the individual (Bourgois, 2000; Bourgois & Schonberg, 2009;Campbell, 2007; Campbell & Shaw, 2008; Hunt & Barker, 1999). This viewworks to obscure larger social and structural factors that shape drug use behaviorson an individual and a community level (cf. Bourgois, 2003; Spradley, 1968). It alsohas the ability to render invisible the fact that psychological and behavioral inter-ventions for addiction constitute disciplinary technologies that act upon the bodypolitic, “the regulation, surveillance, and control of bodies (individual and collect-ive) in reproduction and sexuality, in work and in leisure, in sickness and otherforms of deviance and human difference” (Scheper-Hughes & Lock, 1987, pp. 7–8).It is, therefore, important to attend to the ways in which clinical perspectives onaddiction are professionally and historically situated, lest these paradigms be takenfor granted and their social consequences avoid critical evaluation.

Second, clinic-based addiction treatment programs are governed by a system ofmedical ethics that is inextricably bound up with locally salient ideas about socialidentity and personhood. Like so many other “wide-net” public health interven-tions, OST programs are usually designed to capture individuals displaying certaintypes of troublesome behavior or embodying specific forms of social deviance.In turn, exiting the problematic realm of addiction by submitting oneself to treat-ment is a move equally entangled with social position and discourses of identity.It constitutes a form of work upon the self that Tomas Matza has described as “ameans of sorting value and of ascribing and managing social difference and futures,but also of healing and care” (2012, p. 804). In other words, therapeutic trajectoriesin Ukrainian OST programs are bound up in value-laden social paradigms thatdetermine what makes someone a socially appropriate subject (Carroll, 2011).For addicted patients, much more than their physical or mental health is onthe line.

Third, the illness narratives that are produced and reproduced as part of thetherapeutic process can be, intentionally or unintentionally, spoon-fed to patients.Drug addicts in OST treatment are often presented with a standard clinical narra-tive of what is happening to them with little regard to how their own views of theirphysical states and chemical dependencies may differ. There is a significant body ofliterature in critical medical anthropology that focuses on tensions between actorsin medical and therapeutic settings where social values and meanings of illnessdiverge (Erickson, 2007; Pylypa, 2008). Arguably, the best case for concern over

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the co-occurrence of multiple, contradictory narratives has been made by ArthurKleinman (1988), who has forcefully shown that incompatibilities in the explana-tory models adopted by clinicians and those adopted by patients can have a directand potentially negative impact on the patient’s health outcome. Therefore, failingto map out and attend to the multiple discourses present in the therapeutic encoun-ter can jeopardize a patient’s treatment success and, by extension, their socialfuture.

Above all, I argue that, in the context of the Ukrainian OST clinic, professionalclaims regarding the presence or absence of a patient’s desire to be treated have far-reaching social and moral effects. These claims bolster the validity of OST as amodality of treatment and determine the personal availability of individual drugusers to the mechanisms of that treatment. They leave little room, however, foralternative assessments—least of all the self-assessments of patients who perceivetheir addiction as a practical difficulty, not a psychological one. The result, as thisstudy shows, is that many addicted persons ultimately reject interpretations of theiraddiction and treatment trajectories that contradict their own lived experiences. In sodoing, they also reject the medical authority that seeks to shape their clinical behav-iors and their social engagement, developing their own treatment strategies andimplementing them as best as they can within the confines of their OST program.It is hardly a surprise, then, that “success” on OST appears so difficult to achieve.

Soviet legacies in contemporary drug treatment

Below, I outline the cultural values that have historically characterized professionalapproaches to addiction in the Soviet medical system—from which the contempor-ary Ukrainian medical system emerged—especially the emphasis on individual“will,” which was seen as a lynchpin characteristic in the nature of addiction andpatients’ therapeutic trajectories. It is well established in anthropological literaturethat patterns of addiction are driven by social and structural factors, and that thecharacteristics and meanings of drug use behaviors are largely determined by thecultural context (Becker, 1963; Bourgois, 2003; Bourgois & Schonberg, 2009; BraveHeart, 2003; Pilkington, 2007; Spradley, 1968). Even the most broadly acceptedcase definitions of chemical dependence—those found in the DSM-5 (AmericanPsychiatric Association, 2013) and the ICD-10 (World Health Organization,1992)—rely on culturally bound moral values, such as how much time onespends acquiring drugs or persistent use despite social consequences (Glasser,2011). This fact is highly pertinent in light of Mariana Valverde’s observationthat “scholarly literature on alcoholism and addiction . . . tends to repeat [an] ahis-torical and ethnocentric perspective” (1998, p. 18). It is deceptively easy, sheargues, to overlook how social and moral values have shaped contemporary beliefsabout addiction. In response, anthropologists often view medical interventions forcontrolling or policing addiction’s undesirable elements as socially adaptedtechnologies of governance cloaked in the appearance of the scientifically concrete(Bourgois, 2000; Campbell, 2007).





Throughout the early Soviet period, two etiologies of drug abuse and addictivebehavior fought for prominence: one focused on the social exterior and the otheron the psychological interior of the addict. Both of these approaches sought toarticulate the relationship between environment and addictive behavior and, in sodoing, prescribe an appropriate response. The first of these, which can be called the“social etiology” of addiction, aligned with the foundational principles of Sovietmedicine as established at the 1st All Russian Congress of Medical-SanitarySections in June 1918. It was decided at this congress that emphasis was to beplaced on the prevention of disease via appropriate sanitary and social measures.At this time, leaders in the medical field were especially concerned with “the influ-ence of the economic and social conditions of life on the health of the populationand on the means to improve that health” (Solomon, 1989, p. 255). This socialorientation fell in line with the larger view that the Bolshevik Revolution“eliminated the basic antagonistic contradictions between the socioeconomic struc-ture and the health of the people, and thus did away with the basic source of illnessfor the workers” (Field, 1967, p. 39). In other words, substance abuse and addic-tion were not caused by individual failings; they arose as a result of harsh oroppressive social and economic environments.

Interestingly, this logic led to the brief implementation of an opioid maintenanceprogram in Leningrad in the 1930s. A physician named Kantorovich initiated amaintenance program on an experimental basis, taking in those allegedly “incur-able” patients who, he believed, still displayed the “potential” to become product-ive members of society once more (Latypov, 2011, p. 11). Kantorovich’s claim thatnearly 70% of the patients enrolled in his maintenance program achieved “good”or “satisfactory” results, as measured by the patient’s maintenance of familyrelationships and the stability of employment, flew in the face of the alternativeview, which stipulated that opiate addicts did, in fact, suffer from a “moral dis-ability,” that they were “lacking will” and therefore useless to both country andsociety (Latypov, 2011, p. 11). The alleged implication of Kantorovich’s findingswas that most so-called “incurable” addicts do possess the will to reintegrate intosociety, provided the obstacles that prevent them from doing so are successfullymanaged. He insisted that recovery is possible with the right tools and the personalwill to achieve it.

This approach ultimately lost the ideological battle when the Soviet medicalestablishment adopted psychologist Ivan Pavlov’s concept of the conditionalreflex for its theoretical foundation. As the pioneer of this concept, Pavlov definedthe conditional reflex as an automatic response to certain stimuli that becomesphysiologically hardwired in the brain due to repeated exposure to and neuro-logical analysis and synthesis of those stimuli (Chilingaryan, 1999). Though thisfocus on individual physiology departed from the socially oriented Marxistapproach to public health, it succeeded in articulating a more concrete and trace-able connection between the environment and specific pathologies where Marxisttheories failed. For example, in 1925, Soviet psychologist Mark Sereisky usedPavlov’s ideas to argue that most addicts have a predisposition—a “pre-narcotic

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personality”—and simply need a trigger, such as a first dose of morphine, toawaken the narkomannyi reflex, the psychological “hook” that drives addicts’ com-pulsive behavior (Latypov, 2011, p. 7). The broad acceptance of Pavlovian ideasinto Soviet psychology encouraged clinicians to suspect that if certain stimuli cantrigger addictive behaviors, then different, therapeutically controlled stimuli mightbe able to repress or control them. A particularly striking example of such atherapeutic approach is “coding” [imdhomb‘lhe], which consists of an attempt tophysically rewire the addict’s brain by exposing them to substance-use-discoura-ging physical and psychological stimuli of various kinds, ranging from antagonisticpharmaceuticals to performance, misinformation, and even deception in the healthcare setting (Murney, 2009; Raikhel, 2010).

Though Pavlov’s ideas focus entirely on the effect of exogenous factors onhuman biology and behavior, Eugene Raikhel’s work (2010) on the contemporaryuse of coding and placebo therapy for alcohol addiction in Russia reveals that thepatient’s motivation for sobriety is considered central to the efficacy of the treat-ment. Remarking on the fear- or aversion-based techniques designed to steer thepatient’s behavior away from alcohol consumption, Raikhel has called this treat-ment a “prosthesis of the will, [which allows] for a change in behavior without achange in the self” (2013, p. 190). Many of the most successful patients returnregularly to renew their exposure to the drugs or processes that avert their desireto consume, using treatment protocols as “pragmatic aids for the care of the selfthat bolster the motivations for sobriety” (2013, p. 210). Coding is not understoodas successful due to external stimuli reshaping behavior on its own; rather, thedesire of the patient to seek out those stimuli and, in doing so, reshape theirown reflexes becomes the primary mechanism of recovery.

It is unsurprising, given this history, that clinicians operating Ukraine’s OSTprograms today have forged interpretations of OST as a treatment that embracespatient volition as a central and necessary element of success. OST first appeared inUkraine as an HIV control strategy in 2004 (Bojko, Dvoriak, & Altice, 2013, p. 1),and has remained reliant on—and under the influence of—international donors(especially the Global Fund to Fight AIDS, Tuberculosis and Malaria) ever since.4

However, local (not international) ideas about addiction remain dominant inUkraine’s clinical settings. Even the evidentiary logic by which the efficacy ofOST as a treatment mechanism has been established, the authority of statisticalevidence over clinical expertise, is not widely accepted among the Ukrainian clin-icians (Carroll, 2013; Dunn, 2008). As the following sections will reveal, manyclinicians perceive addiction as a context-dependent battle between the consciousdesires of the addict and the drug-seeking behaviors that they find necessary.OST is interpreted, in turn, as a tool with the capacity to intervene in this conflict.Each patient’s personal battle is one that, with the right support and scaffolding,can be won if they possess a conscious desire to change. It is a battle, however, thatcan’t be won without the conscious desire to change, and the success or failure ofOST as an intervention is a direct measure of individual will.





The discourse of desire

There are two common ways to discuss “wanting” in the Russian language, thelanguage of choice for all but a few of the patients and clinicians I interviewed.5

The first is to use the verb tmqeq{ (khotet’), which means, “to want.” One can usethis verb to indicate very straightforward desires such as “I want to become ateacher” (Russian: _ tmvr pq‘q{ rvhqejek) or “I want milk in my coffee”(Russian: _ tmvr imse p kmjmimk). The other way is to use not a verb but anoun: fej‘lhe (zhelanie). In English, the word fej‘lhe (zhelanie) means “desire.”It also means “wanting,” or “longing,” or “will.” It lends itself to the same kind ofpoetic license in Russian as it does in English. You can ascribe to someonefej‘lhe rkeoeq{ (zhelanie umeret’), a death wish. It is possible to cmoeq{

fej‘lhek (goret’ zhelaniem), to burn with desire. The Russian language evenshares the idiom azjm az fej‘lhe, ‘ rkelhe l‘—dˇqp~ (bylo by zhelanie, aumenie naidyotsya), where there is a will, there is a way.

The distinction between these two modes of representation is important.While it is possible to want (Russian: tmqeq{) or not want (Russian: le

tmqeq{) something without great moral consequence, desire (Russian: fej‘lhe)is a much more innate human characteristic without which there would be littledrive to act at all. The absence of desire is indifference. Thus, to accuse addictsof having or not having the desire to be treated is, in essence, to assert that theyare either driven, morally active persons or passive, indifferent, emotionallyunengaged persons who are beyond help. The actions of Alexey Sergeevich’sshirka-using OST patient Timur—his ardent refusal to decrease his dose andhis unwillingness to comply with the OST program’s prohibitions against theuse of street drugs—fall squarely into the discursive realm of fej‘lhe (zhe-lanie). Timur has been told how to treat his addiction. He has been given thetools that he needs to do so. Yet his problematic drug use persists. Theproblem, his doctors say, is not that he is physically incapable of quitting.Instead, Timur’s behavior is iconic of a problem that clinicians claim plaguesso many of their clients. Timur suffers from a lack of desire—a lack of fej‘lhe

(zhelanie).Nearly every clinician I have met in Ukraine has complained to me about the

lack of fej‘lhe (zhelanie), the lack of this conscious desire to change, among someor all of their addicted patients, especially those who do not specialize in addictiontreatment. The head doctor of an HIV clinic near Kyiv once threw up his hands inexasperation when I asked about the number of AIDS deaths among injection drugusers. “These deaths,” he said, “are related to the anti-social element. They strovedirectly to the grave. They had no desire to live [Russian: S lht fej‘lh~ fhq{ le

azjm]!” A tuberculosis specialist in a different hospital voiced a similar complaint.As I sat in her office, she scowled and looked behind me to a group of men millingoutside the entryway of her department. “Doctors tell them to come here [to thisoffice to receive antituberculosis pills],” she said,

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[B]ut they just hang out, they talk in the hallway, and then they leave. They are

alcoholics, drug users. They have no desire. [Russian: Gej‘lh~ leqr]. Maybe the

wife already died, the daughter is already sick. It’s all the same to them. They need

narcotics to deal with their psychological problems. That’s addiction.

Clinicians who work directly with OST patients perceive the same pattern amongtheir patients; however, they are much more delicate about applying meaning toeach individual case. One social worker, who has been advocating for the expan-sion of OST in his region since it first became legal in 2006, elaborated on thisdistinction as follows:

It is important to understand that there are three kinds of addicts. First, there are

those who used street drugs, but managed to fully substitute those street drugs with

methadone. They slowly lowered their dose, and eventually quit. But remember, even

after they quit, they are still addicts. There is no such thing as a former addict

[Russian: Bzbwht l‘oimk‘lmb le azb‘eq]. Second, there are those who don’t even

think about quitting [Russian: Bomp‘q{ le drk‘}q]. They like to keep their metha-

done regimen at the maximum dose—maybe 150 mg—rather than working to slowly

decrease it. They may want to quit, but they are too afraid—afraid that they will

return to narcotics on the street and completely relapse. The last group is those

who never think about quitting methadone and never plan on quitting street drugs

either. They continue to use whatever they want the whole time they are on metha-

done—things like shirka.

This taxonomy was repeated to me with different words but similar content bymany other clinicians. Within this framework, clinicians engage the individual willas a quasi-diagnostic category. If you have it, you will get better. If you don’t, youwon’t. Interestingly, the ability of the drugs distributed by OST programs to effectchange is also determined by a patient’s position in this schema. Treatment efficacyis seen as modulated by the desires of each individual patient to be a subject of thattreatment. OST, then, is not exactly a “prosthesis of the will” (Raikhel, 2013).Rather, it is perceived as an extension of the will.

According to the paradigm of addiction embraced by international healthorganizations (World Health Organization, 2004), OST does not operate by enga-ging individual desire. Rather, it works by shutting desires off. The dominantinternational view holds that OST “works” by “‘block[ing]’ the euphoric effectsof heroin, thereby discouraging illicit use and thereby relieving the user of the needor desire to seek heroin” (Mattick, Breen, Kimber, & Davoli, 2009, p. 5). OST isoften considered a form of “harm reduction,” an approach that “frame[s] substanceuse practices in terms of a series of choices around consumption along a range ofpossible actions, from the most harmful (e.g., sharing needles) to the least harmful(abstinence)” (Lovell, 2013, p. 145). By blocking euphoria and simplifying thelogistics of staving off withdrawal symptoms, OST, according to this framework,engages with drug users as rational actors, aiming to alter their behavior by





reshaping the factors that affect their decision-making. In this view, each patient’sinternal desires are relevant only insofar as the desire to use drugs is successfullymodulated by the intervention, rather than the intervention being modulated bydesire. Thus, in the international ideal, OST serves as a disciplinary technology forlimiting and controlling desires and, by extension, controlling behaviors linked tothose desires.

Though the establishment of OST programs on the basis of this an approachwould seem to unseat patient desire from its central role in patient recovery, thediagnostic value of “desire” has remained powerfully salient in Ukraine. Certainpractical understandings of desire—the patient’s social volition to seek treatmentand regain an acceptable level of sociability—are fundamental to professionalunderstandings of addiction in Ukraine and have been for nearly a century. Thismode of thought is an inextricable element of the Ukrainian context in whichinternational standards for OST must be—and have become—situated.Standardized protocols may shape the daily activities of the clinic, informing pro-cesses like patient tracking, diagnostic procedures, and direct observation of treat-ment, but the structure that these standards prescribe forms only the backgroundagainst which doctors and patients carry on their own discourse with each otherabout what OST can accomplish and how patients should make themselves avail-able to this treatment in order to achieve success. In particular, Ukrainian doctorsmake especially strong claims to expertise on the clinical management of addictionbased upon their alleged familiarity with desire and indifference in their patients.They have spent enough time with such patients, many claim, that they can identifydesire when it is present and note its absence when it is not. For me to gain a betterunderstanding of just how important desire really is, I was often told, I would alsohave to learn to read these signs—to see as they did past the words and behaviorsof their patients into their motivations. This would help me see what addictiontruly is and what OST can do about it.

The interpretation of wanting

My first practical lesson in “reading” a patient’s desire came from a man namedSergey Tonenko, a program consultant who has advised substitution therapy pro-grams across Ukraine. Sergey invited me to accompany him on a number of hisvisits to various OST sites. He introduced me to clinicians and NGO leaders in anumber of cities and provided me with an informed perspective on how thesedifferent medical and social service entities interact with each other. During thefall of 2012, I spent several weeks visiting eight OST sites, located in five differentcities, in Sergey’s company. Our first journey together took us to an OST clinic in atuberculosis hospital located in a southern region of Ukraine, whose enclosedgrounds overlooked the rugged shore of the Black Sea.

Before entering the hospital, at the request of the head physician, we purchasedsimple masks to protect vulnerable patients in the hospital from any infections wemight have brought with us. We crossed the street in front of the hospital, entered a

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little basement pharmacy, and stood in line for our turn with the pharmacist at thewindow. As we waited, the woman at the front of the line completed her purchaseand walked passed us towards the door. Her fist was clenched tightly around hernewly acquired goods. Sergey whispered “It makes me so sad to see that.” When Iresponded with a confused look, he explained what he had seen in her hand. “She isbuying needles and eye drops. It was tropicamide. This is common here. Drug userswill drink it, or sometimes inject it. I don’t know what it is supposed to do, but lotsof people use it.” Tropicamide is an anticholinergic eye drop that is frequently usedto dilate the pupil during eye exams. Anecdotal evidence collected during thecourse of my research indicates that tropicamide may act as a mild hallucinogenor that it may amplify the effects of opiates, even when opiate-receptor blockers,such as those used to decrease the euphoric effects of prescription methadone, areingested. Once Sergey and I purchased our masks, we hurried back across the streetto the hospital. We were accepted graciously onto the hospital grounds. Sergeygreeted the staff affectionately, and I was properly introduced. Tea and cookieswere distributed, and Sergey conducted the necessary business of his official sitevisit, which included a brief survey with the doctors and an inventory check.

The recruitment of OST patients for interviews began on this trip, as on everytrip I made to each new clinic, with a phone call. I, or sometimes a local contact(in this case, Sergey), would speak briefly to the clinic’s head physician about myresearch and schedule a meeting to request the physician’s assistance in recruitingpatients. I hoped that each doctor could tell clients about my research and offerthem a chance to contact me if interested. Often, clients were intrigued by my pres-ence and approached me independently to ask about my work and offer theirpersonal perspectives on addiction and OST. The first patient we met in this fash-ion was a young woman who had been lingering in the hallway drinking free coffeewith a nurse. Intrigued by our presence, she let herself into the doctor’s office to seewho we were. As she strode confidently through the door, I immediately recognizedher as the woman we had seen just moments prior, purchasing needles and tropi-camide at the pharmacy.

She told us that her name was Lyuda. She had only been part of the programfor a year and a half—not very long compared to some of the other patients there.She was frustrated with the program.

L: Do I like [OST]? No. At the beginning, when I first came here, I thought it

would solve all my problems, like, I didn’t have to hunt for money, didn’t have to

find drugs on the street. I just came here, took my pills, and went about my

business. But after a while . . .well, I can’t go anywhere. Not even on weekends,

just to visit anyone. It doesn’t even matter where. I can’t. Because every morning,

even on New Year’s Day, January 1, everyone else is asleep, and I, like a

fool—forgive me—I get up and I come here. So, at the beginning it’s nice, but

it’s this vicious circle. And I can’t quit. I can’t go without this [the metha-

done] . . . psychologically it’s very hard.

JC: And how did you come to the decision to start this program in the first place?





L: I had a baby. I can’t tell you if I am a good mom or a bad mom, but I try. And I do

this in order to spend time with her—nearly all my time, not counting the 2 hours

I spend coming here every day. I joined the program so that I could be with her.

Interestingly, Lyuda displays characteristics associated with two different “types”of drug users—according to the clinical taxonomy described earlier. On the onehand, she articulates her decision-making in such a way that highlights how she hasprioritized her motherly duties. She needs to spend time with her daughter, so shehas taken steps to reduce the portion of her day that she spends acquiring narcoticsby switching over to a quick and reliable source: OST. Her decision to begintreatment constitutes a management strategy designed to keep her multiple prio-rities in order. She was sacrificing the attention she gives to one (her addiction) sothat she can afford greater attention to the other (her daughter). The disparagingassessment of the TB nurse, who insisted, “they have no will . . . It’s all the same tothem [because] that’s addiction” does not easily apply in this case. By prioritizingher duties to her child over some of the immediate necessities of her opiate depend-ence, Lyuda is testifying to her possession of the very desire that clinicians sayaddicts need in order to recover.

On the other hand, through her extracurricular drug use, Lyuda is also stra-tegically controlling the effects of methadone on her body. By adding tropicamide(and perhaps other substances) to her regimen, she is taking steps to alter, adjust,or amplify how she feels on the methadone. Her attachment to the physiologicaleffects of her controlled opiate regimen is obvious in the actions she takes tomodulate and maintain them. This is part of the risk of getting caught: not onlycould she be punished by the program staff, she would also have to overcome thestigma that accompanies an unwillingness to bear the physical effects of decreasingher methadone. She would have to face the consequences of being labeled“indifferent.”

As our conversation continued, Lyuda voiced skepticism about OST as a mech-anism for treating addiction and subsequently ending one’s drug use. She clearlyarticulated her position that the desire to quit was not sufficient for overcoming herdependency, despite her participation in OST and regardless of how serious ordeeply held that desire might be.

JC: How would you describe, in your own words, the goals of this program?

L: To lower . . . I mean, the program gives people . . .we try to live like normal, healthy

people. But the truth is that we don’t always succeed. Because the brain of an addict is

always searching for a high [bpe boek~ tmveqp~ i‘—s], and here there’s no high. Here

it’s just, like, I take my pills and I feel fine. Nothing hurts, I sleep regularly, I eat

regularly, and everything’s fine. And the whole time your dose is decreasing down to

that minimum and then you’re already going without and we live like normal people.

But the reality is that this takes a really long time. A year. Two. It depends on the

person. I’ve already been here for a year and a half and I’m not ready to give it up.

JC: What is it, then, that you would like to gain for yourself?

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L: For myself? Honestly? I’d like to wake up in the morning and know that I’m

healthy. But that morning won’t be coming anytime soon. Because every morning I

wake up with just one thought on my mind: I need to get dressed and head out for this

place . . . but I’m really tired of it.

JC: If you felt able to, would you want to quit taking methadone entirely?

L: I want to, but I’m not psychologically ready for it. I just know that if I go off the

methadone, maybe a week will go by, not more, and I’ll start looking for street drugs

again. Cause, here [pointing to her chest], it’s not just physical, here [pointing again to

her chest] it’s more important than you could even think.

JC: What do you mean by “ready” to quit? What does “ready” mean?

L: Ready to quit and live like normal people. I can’t say that I’m ready because I’m

still craving the next high all the time . . . in my head. I struggle with it. I have this

daughter who is growing up so fast, and I am very well aware that I need to stop, but

it hasn’t happened for me.

Lyuda was the first person I heard speak about feeling “stuck” in an OST program,unable to change or to quit, but she was far from the last. Gaining an understand-ing of local paradigms of addiction was one of the primary goals of my research, soI always inquired about the treatment plans that addicts had designed for them-selves. I asked about what quitting methadone would signify for them, about whatit meant to be “ready.” I asked how they would be able to recognize if and whenthey ever were. My questions were met with a constant refrain: “I want to quit, butI’m just not ready.” The significance of this phrase was compounded by each newpatient who uttered it.

What struck me about this particular moment at the TB hospital, and whatSergey tried to drive home to me as we left the clinic that day, was the conflict thatLyuda, the loving mother who topped off her methadone with tropicamide, pre-sented to her medical providers. Both Sergey and Lyuda’s physician at the OSTclinic tried to coach my interpretation of this encounter, telling me that Lyuda willnot be successful in her efforts to maintain control over her competing familial andchemical obligations. I was especially encouraged to see Lyuda as deceiving herself.She may talk about her daughter and claim a desire to live peacefully with herfamily, but this just isn’t realistic. She would never be able to quit using drugs untilshe really wanted to; her tropicamide use is evidence that she doesn’t. She’s notletting herself be treated; she’s just as addicted as her first day in the clinic18 months ago.

The metaphysics of addiction

Many months into our acquaintance, Sergey and I found ourselves sitting acrosshis kitchen table, eating linden flower honey from the jar with a spoon and onceagain discussing the so-called successes and failures in OST that he had witnessedthroughout his career. Sergey quietly pondered my questions about what makesOST “successful” for some drug users and not for others. I had asked him these





questions dozens of times, and, by then, they had become almost rhetorical—partof our regular exercise of thinking through what he believed addicts were really upto in these programs. “Of course you have to have the desire to change yourbehavior,” he said, switching from Russian to English, which he often did toemphasize a point. He said:

Drug users, they must have this desire to quit, because the behavior is bad. But the

sin—the consequence—of this behavior is that it destroys your constitution—the thing

inside of you that should be the strongest. So, when you are addicted, you understand.

You know what is happening to you. But you can do nothing about it.

What Sergey was working so hard to articulate is a psychological profile of addic-tion based upon a dualistic understanding of human consciousness. He explainedthat addiction is characterized by the inability to act upon one’s inner desires. Youwant to quit, but you have lost the self-control needed to do so. He explained thateach one of us possesses a mind, a body, and a metaphysical connection betweenthe two. When we are sober, all three elements are strong and intact. When we usedrugs or alcohol, one or more of them becomes compromised.

He also explained that clinical professionals are able to intervene in this quan-dary by generating and then hooking the desire of a patient. It is that very desire, infact, upon which many treatment professionals hope their efforts will havean effect:

If someone is seeking rehabilitation with a psychologist, their success will depend on

their motivation. They must want to change. The psychologist cannot do all of the

work. But the addict cannot get better without the help of the psychologist.

Sometimes the patient is motivated inside and just needs to find help. Other times,

the psychologist must be skilled at generating their interest, building their desire,

lighting a fire in you to change your ways.

When people are involved in substance abuse, he argued, their mind, their will,loses its ability to act upon them the way they want it to. As they become more andmore addicted, drug users are able to see themselves losing control. They may evenretain their desire to be in control, to live their lives, to maintain their relationships,but they are unable to. This is why both professional treatment and the desire to betreated are necessary for overcoming addiction.

A Ukrainian harm reduction activist named Svetlana articulated this same logicto me. She described this weakened connection between mind and body as anillness in one’s soul. She explained,

We know that a doctor can only help with 10%. The other 90% is for you to work on.

This is true for any disease, everywhere. A drug-addict is an ill person: ill psycho-

logically, physically, and in the soul. Their soul is ill. But they can’t just sit and wait.

They have to go to NA groups, therapy, look for the way out.

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If they have no desire, she insisted, their situation will never improve; however, ifthey maintain an internal desire to change their lives, or if a skilled psychologist orsocial worker is able to generate such desire within them, then drug treat-ment—including substitution therapy—can be the last piece of the puzzle. It is anecessary step towards realizing those desires, and a step that addicts must activelyseek. They have to want to find that help.

After hearing these professionals map out the psychological and emotional ter-rain of addiction in this way, I began seeing echoes of these ideas in my interviewswith OST patients. For example, I met a woman in an OST program in Kyiv whoexplained her initiation into drug use with a similar gap between her desires forherself and her personal control over her drug use:

When I started, we had no drug addicts in our village. I had no idea that I would end

up like this, living the life that I’m living now. You know, there are some people who

like drinking. They like the feeling. I don’t. I never enjoyed the feeling of being drunk.

I did other things. But the purpose of all of it is just to relax a bit, right? But, unfor-

tunately, it wasn’t that kind of relaxation. It alters your perception of reality, making

everything fluffy around the edges. And you have these moments where you realize

that you’re tired of all of it, tired of using, but you go out looking for more just the

same. You hunt, you buy, you cook, you shoot it up. You’re even doing it when you

have no veins left, even after you’ve been sitting for 2 or 3 hours looking for a place

where the needle will hit.

This frustration, this sense of wanting to stop but simply having no control overone’s use, is also apparent in Timur’s recollection of his path in and out of differenthospitals and treatment programs. “The point is not to raise your dose,” he said.“But to lower it . . . I want to quit, but [the narcotics] are holding on too tightly tomy body.” Timur claims that he has a desire, but the nature of addiction makes itimpossible for him to regain the control he needs to make that desire a reality. Themajor difference, however, is that these patients insist that they desire to quit inspite of their failure to progress on OST. For them, OST can intervene on theirdaily logistical troubles, but not on the root psychological elements of theirdependency. As clinicians mark them as failures, blaming their difficulties on adeep-seated indifference, patients frame their entire lived experience with addictionas saturated in frustrated and unsatisfied desires. They insist that, in the face of allof this, they are doing the best that they can.

Reflections

International protocols for the implementation of OST may be considered a hege-monic discourse. As Erin Koch has noted in her analysis of standardized tubercu-losis treatment in the Republic of Georgia, “the cultural, historical, andinstitutional processes within which standardized [international] medical protocolsand standards are made and circulated globally are rendered invisible” (2013, p.





58). However, Koch’s ultimate position, and mine as well, is that these standardsconstitute an ideal that can be attempted in all places but achieved in none. Asthese international approaches move across national, cultural, and geographicboundaries, they will become situated within local discourses that fit or contradictthese ideals to varying degrees. International paradigms will necessarily be reinter-preted and incorporated into the local context wherever they go. Ukraine is noexception.

OST clinicians in Ukraine are adopting a clear and prescriptive interpretation ofthe medical terrain where addiction, psychology, and personhood intersect. Peoplelike Timur and Lyuda, however, are levying their own claims as well. They both arequick to take ownership of their self-management strategies and to defend thevalidity of their efforts. It is clear, though, that these strategies, whether they areseen as attempts to simplify logistics or deliberate moves towards socially accept-able citizenship, are not equally valued by their medical authorities. Throughouthis time in as an OST patient, Timur has displayed complex and creative treatment-seeking behaviors. He goes by his clinic at 10:00 a.m., like clockwork, every day.He is a regular visitor of his city’s other harm reduction programs. He is open andhonest with all of the social workers that interact with him. He takes medicalconsultations when they are offered. Yet he is not seen by OST professionals ashaving any desire to improve his situation. Similarly, Lyuda’s claims of motherlyduty are rendered invalid because she is a mother who uses drugs. Her tropicamideuse is taken as a sign of her indifference to her health and well-being, rather than anattempt to exert more control over her physical and mental state.

If we consider the premise that addicts become defined and targeted by publicinterventions like OST because something about them is socially problematic, it islogical to expect that the addict’s recovery will be defined by their reentry into thesocial fabric as a less problematic agent. E. Summerson Carr has observed thislogic in American treatment programs where addicts are considered troublesomebecause they are epistemologically problematic (2010). They are seen as unable torecognize their own personal states and are, therefore, unable to produce honest,unfiltered speech that reflects those inner states. Since the problem is that theycannot be trusted, addicts’ treatment trajectory, if successful, will be defined bythe emergence of appropriately regulated speech. In Ukraine, addicts are seen asproblematic and dangerous not only because addiction, as many clinicians claim,can only arise in someone who is indifferent. Indifference disconnects people fromtheir primary social relationships. That lack of integration is what makes themtroublesome, and it is what treatment efforts aim to resolve.

The theory that addiction traps the will by forcing the addict to lose control ofhimself reaches far throughout the biomedical sphere and even the popular imagin-ation in Ukraine, ascribing meaning to a vast array of behaviors, urges, and statesof consciousness. Timur and Lyuda’s persistence, though, reveal the cracks aroundthe edges of this theory. They show that the dominant psychological approach toaddiction treatment in these crucial programs captures only a part of the livedexperiences that they hope to influence. Ultimately, the clinical paradigm of

Carroll 15




addiction that has taken hold among the professionals operating Ukraine’s OSTprograms must be understood as a discourse that exists in concert with thediverse narratives, strategies, and identities that drug users adopt to managetheir bodies, their identities, and their lives. A failure to recognize this willhinder the ability of OST programs to produce positive outcomes among thepatient population. It will leave many addicted persons, especially those who donot share this clinical view of themselves, effectively on their own to developstrategies for making sense of their experiences and making peace with theirbodies, physical and social.

Funding

The research presented in this article was supported by the Wenner-Gren Foundation, IREX(International Research & Exchanges Board) with funds provided by the United States

Department of State through the Title VIII Program, and the Department ofAnthropology at the University of Washington. None of these organizations are responsiblefor the views expressed herein.

Acknowledgements

All research methods and protocols were reviewed and approved by the Human SubjectsDivision at the University of Washington. This article includes material that was presentedat a conference entitled “From the New Socialist Person to Global Mental Health: the Psy-

ences and Mental Health in East Central Europe and Eursaia,” which was hosted by theUniversity of Chicago in April 2013. I am extremely grateful to the participants of thisconference as well as to the anonymous reviewers for their thorough and helpful criticisms.

I offer my deep gratitude to Laada Bilaniuk and Janelle Taylor, who have offered unwaver-ing support throughout this research process. I am also particularly indebted to EugeneRaikhel and Grzegorz Sokol, whose intelligent dialog and thoughtful feedback on this workhave been invaluable.

Notes

1. All proper names have been replaced with pseudonyms.

2. Shirka (Russian: whoi‘) is a commonly used street drug in Ukraine. It is made byprocessing homegrown poppy straw with an anhydride and other solvents to extractthe opium content. The resulting product is a high-volume (somewhat diluted) and

allegedly “softer” alternative to heroin.3. A pharmaceutical opioid analgesic similar to codeine.4. OST programs across Ukraine are supported by Global Fund grants as part of the

nation-wide HIV control strategy. For this reason, OST programs are often housed inregional HIV/AIDS centers, as well as in regional tuberculosis hospitals, as HIV/TBcoinfection is common. Despite sharing its premises with these larger health care insti-tutions, legal and financial regulations require that OST services be physically separated

from other hospital services. Separate, controlled rooms must be designated for the stor-age and distribution of OST drugs, meaning that patients with a dual or triple diagnosismust go to one part of the facility to receive antiretroviral or antituberculosis medication

and then to another part of the facility to receive their daily dose of OST. Certain oblasts





of Ukraine offer methadone in a syrup form by prescription for patients who can provehardship or an immediate need to travel, but the vast majority of patients must receivetheir drugs under the direct observation of a nurse in the clinic to which they are assigned

on a daily basis.5. Though Ukrainian is the official language of Ukraine, many residents are native speakers

of the Russian language and the majority of Ukrainian citizens are, to varying degrees,

bilingual. Though the reality of language politics in Ukraine is more nuanced and com-plicated, the situation is often generalized as follows: Ukrainian is more often thecommon language for public interaction in rural areas and in western urban centers;

Russian is more often the common language for public interaction in eastern regionsand central and eastern urban centers. In some places, especially in the capital city ofKyiv, it is not uncommon to hear conversations take place in both languages, with oneperson speaking in Russian and another responding in Ukrainian (for more on this topic

see Bilaniuk, 2004, 2005; Chumak-Horbatsch, 1999; Friedman, 2010). Because much ofthe data presented in this article was collected in central, southern, and southeast regionsof Ukraine, where Ukrainian is often taught or engaged only as a second language, the

linguistic elements of this analysis have been grounded in the Russian language and therepeated vernacular (especially the use of the word fej‘lhe [zhelanie]) used by cliniciansand patients alike to reference the symbolic terrain of desire.

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Jennifer J. Carroll, MA, is a doctoral candidate at the University of Washington,where she is earning a PhD in Anthropology and an MPH in Epidemiology. Shealso holds an MA in Sociology from Central European University and a BA inAnthropology from Reed College. She researches drug use behaviors, addictiontreatment, and HIV prevention efforts in Ukraine. More broadly, her researchinvestigates current global health paradigms and supports critically engagedpublic health policy. Her published works focus on bio-medical systems, scientificontology, the construction of identity, and the lived experience of addiction.

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for lack of wanting

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